Name

Date Of Birth

Phone Number

Email

Mailing Address

Drug Of Choice?

Date Of Last Use?

Who Is Financially Responsible For Your Stay?

Text

What Is Their Mailing Address?

What Is Their Phone Number?

How Did You Hear About Live Free (Family, Treatment Center, Therapist)?

Do You Have Allergies (Food or Environment)?

What Hobbies Or Interests So You Have (Exercise, Music, Hiking, Etc.)?

Do You Have A Mental Health Diagnosis? Do You Have A Mental Health Diagnosis? Yes No

What Medications Are You Currently Taking?

Have You Ever Attempted Suicide? Have You Ever Attempted Suicide? Yes No

Do you have a history of self-injurious behavior? Do you have a history of self-injurious behavior? Yes No

Are You Currently On Probation Or Parole? If So Where?

Have You Ever Been Convicted Of Arson? Have You Ever Been Convicted Of Arson? Yes No

Have You Ever Been Convicted Of A Sex Crime? Have You Ever Been Convicted Of A Sex Crime? Yes No

Live Free asks that you be willing to commit to staying here for a minimum of 3 months and also be willing to fully participate in our program: Is This Something You Are Willing To Commit To? Live Free asks that you be willing to commit to staying here for a minimum of 3 months and also be willing to fully participate in our program: Is This Something You Are Willing To Commit To? Yes No

What Date Are You Looking To Be Admitted?

Emergency Contact Information (Name & Phone):